Chest
Volume 108, Issue 3, September 1995, Pages 828-841
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The Diagnostic and Therapeutic Utility of Thoracoscopy: A Review

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Simple Rigid Thoracoscopy (Without Video Assistance)

Simple rigid thoracoscopy (without video assistance) must be differentiated from VATS (with video assistance). Simple rigid thoracoscopy is the use of a metal, illuminated scope placed into the pleural space for the purpose of diagnosing pleural disease or performing minor therapeutic maneuvers such as pleurodesis. Video equipment is not used. Operators can use a lighted mediastinoscope, thoracoscope, or laparoscope. The mediastinoscope offers a large working channel and provides for excellent

Pleural Disease

Pleural effusions occur as a consequence of local disease of the lung or pleura or as a manifestation of systemic disease. The relative ease of access to the pleural space allows pleural fluid and tissue to be evaluated diagnostically. Conventional sampling consists of thoracentesis and percutaneous closed pleural biopsy. Thoracoscopy is often performed because these procedures are nondiagnostic.

Cytologic analysis of thoracentesis fluid is positive in 45 to 80% of malignant pleural effusions;

Overview

Simple rigid thoracoscopy is still used for effusion management, pneumothorax repair, and drainage of uncomplicated empyema or hemothorax. With the development of endostaplers and refinements in instrumentation, thoracic surgeons are also performing VATS procedures for many indications previously reserved for open thoracotomy.

The Video-Assisted Thoracic Surgery Study Group7 was formed to collect and analyze standardized data in an effort to characterize VATS and its current role in

Morbidity

Known complications of thoracoscopy include bleeding, empyema, wound infection, prolonged air leak, tumor seeding at the entry site, and death.7,10, 11, 12, 13, 14 It is difficult to summarize the overall complication rate because it depends on the indication, type of anesthesia, equipment, patient population, and experience of the operator.

The incidence of subcutaneous emphysema with thoracoscopy ranges from 0.5 to 7%.28, 29, 30 The risk of infection appears to be low, with only 5 (0.5%)

CONTROVERSIAL ISSUES IN THORACOSCOPY

Who should perform thoracoscopy, pulmonologists or thoracic surgeons, is a primary topic of debate. Procedures such as diagnostic pleural biopsy and talc poudrage are currently being performed by select, experienced pulmonologists with a 90% sensitivity and high degree of safety.14,58,85 Unquestionably, most therapeutic and operative procedures are the domain of the thoracic surgeon. It is imperative, therefore, that the pulmonologist and thoracic surgeon have a close working relationship to

CONCLUSIONS

Modern thoracoscopy provides a potentially less invasive means to diagnose and to treat a variety of intrathoracic diseases (Table 3). Simple rigid thoracoscopy is safe and effective for the diagnosis of benign and malignant pleural disease. It is useful for therapeutic procedures such as pleurodesis and uncomplicated empyema drainage. Current endoscopic and VATS techniques have the potential to limit morbidity and reduce hospital stays for major operations. This ability, however, provides the

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